Maraleto's Insurance - Health Insurance Broker - Medical Insurance Broker

What We Offer

Professional Liability / E&O

Professionals such as physicians, lawyers, accountants, real estate brokers and insurance brokers secure themselves against liability claims with professional liability insurance. The policy covers for any claims against them for damage or losses that may be suffered by their clients in the course of their professional services.

* =Required Fields
Primary Insured
1.	* Applicant Name
2.	Address:
	* Street Address 1:
	Street Address 2:
	* City:
	State:
	* Zip Code:
	* Phone:
	* Email:

Professional Service(s):

P r i m a r y

Revenue ($)
Revenue (%)
S e c o n d a r y

Revenue ($)
Revenue (%)
T e r t i a r y

Revenue ($)
Revenue (%)
T O T A L
Revenue ($)	Revenue (%)

4.Is the Applicant Firm controlled, owned, or associated with any other firm corporation or company?
Yes No
If Yes, please provide details here:

5.Number of Years in Business:

6. Average number of years of related professional experience for all Partners, Principals and Key Employees :

7. What percentage of services are rendered under a written contract?

8. Have any claim(s) been made against any proposed insured(s) during the past three years?
Yes No
If Yes, please provide details here:

9.Have any Partners, Principals or Key Employees ever been the subject of disciplinary action by authorities as a result of their professional services?
Yes No
If Yes, please provide details here:

10.Does any person or entity proposed for insurance have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim under the proposed policy?
Yes No
If Yes, please provide details here:

11. Has any similar insurance ever been declined or cancelled?
Yes No
If Yes, please provide details here:

12.Is similar insurance currently in force?
Yes No
If Yes, please provide:
Name of Carrier.
If Other.
Expiration Date
Limit		$
Deductible		$
Premium		$
Retroactive Date

13.Please provide the number of years of continuous coverage


It is agreed with respect to Questions #8, 9, and 10 above, that if such knowledge or information exists any claim or action arising therefrom is excluded from this proposed coverage.
Policy Coverage Details
1. Limit of Liability (Each Wrongful Act/Aggregate)
3. Deductible (Each Wrongful Act/Aggregate)
Other information you would like us to know:

Companies

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Phone

714-323-5301

Medicare Calls

714-276-8584

Email

Main Office

PO Box 5217
Huntington Beach, CA 92615

Office Hours

Mon–Fri: 8:00 AM – 6:00 PM
Sat: 9:00 AM – 1:00 PM

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Last Name

Email Address

Phone Number

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ZIP Code

Additional Notes

When you fill out our form, you will receive health insurance quotes from Aetna, Anthem Blue Cross, Blue Shield of California, Health Net, PacifiCare & United Health Care. We'll help you find individual, family or small business health insurance and the best medical insurance plans for your needs and budget.